State of California-Health and Human Services Agency California Department of Public Health Food and Drug Branch HOME MEDICAL DEVICE RETAILER LICENSE APPLICATION PLEASE COMPLETE THIS FORM FULLY—INCOMPLETE APPLICATIONS WILL BE RETURNED See page 2 for instructions NEW APPLICANT RELOCATION OWNERSHIP CHANGE 1. Legal Name of Firm OWNERSHIP AND LOCATION CHANGE RENEWAL 9. Facility Operator (name and title) 2. DBA (List additional DBA’s on separate sheet if necessary.) 10. Facility Telephone Number ( 11. Facility FAX Number ( ) ) 3. Facility Address (number, street) 12. 24-Hour Emergency Telephone Number 13. E-mail Address 4. Facility Address (continued) 14. Correspondent (name and title) ( 5. City State ZIP Code ) 15. Correspondent Telephone Number ( 16. Correspondent FAX Number ) ( 6. Mailing Address (if different or P.O. Box number) 7. Mailing Address (continued) ) 17. Country (if other than United States) 18. Website (URL) 8. City State ZIP Code 19. Type of Ownership Individual/Sole Proprietorship Partnership Corporation/Limited Liability Company Other:_____________________ (attach copy of Partnership Agreement or Articles of Incorporation) 20. Corporate Name (if applicable) State of Incorporation 21. Owners’ or Officers’ Names and Titles Owners’ or Officers’ Names and Title s (Attach a separate list if needed). 22. Type of Application New HMDR (never licensed) New HMDR (additional location) New HMDR (ownership change) __________________________ New HMDR (address change) ____________________________ (previous HMDR license number) (previous HMDR license number) Renewal of an existing HMDR ____________________________ HMDR Warehouse Only (storage) ________________________ (HMDR license number) (retail facility HMDR license number) Retail Sales/Distribution Business days and hours:_____________________ 23. Type of Business to be Conducted at this Location: Warehouse Only Business license Number:____________________ (attach copy of business license) Federal Employee Identification Number (FEIN):____________________ (attach copy of FEIN) Seller’s Permit Number:______________________ (attach copy of Seller’s Permit) 24. The applicant retailer will be selling the following products: (check all that apply) * Asterisk indicates legend device - must have Pharmacist-in-charge (PIC) or a Licensed Exemptee on premises. ** Asterisks indicate product may be a legend device. Respiratory Equipment/O2 Supplies* CPAPS, BiPAPS* TENS Units* Infusion Pumps* Catheters* CPM Machines Incontinence Supplies Custom Wheelchairs Power Wheelchairs ** Manual Wheelchairs Nutritional Supplements Diabetic Test Supplies ** Walkers, Canes, Commodes Hospital Beds/Mattresses Air pressure Mattresses* Other—describe below or attach list of products ______________________________________ 25. If the HMDR facility will be selling/renting legend devices, respiratory equipment, or medical oxygen: Yes No (If Yes, attach a copy of PIC card) a. Will there be a pharmacist in charge (PIC) of operations at this location? b. Will there be an HMDR exemptee in charge of operations at this location? Yes No (If Yes, attach a copy of exemptee license) Name: ________________________________________________________ Exemptee License Number: ________________________________ Name: ________________________________________________________ Exemptee License Number: ________________________________ 26. Do you have a Medi-Cal or MediCare Provider number? (If currently applying for one, please check the Pending box) Medi-Cal Provider? Yes No Pending Yes No Pending Medicare Provider? MAKE CHECKS PAYABLE TO: 27. Payment Codes (Check only one code—see page 2 for schedule.) A—$850 B—$850 C—$425 (Fee is Non-Refundable) CA DEPARTMENT OF PUBLIC HEALTH See page 2 for mailing address. Under penalty of perjury, under the laws of the State of California, each person whose signature appears below, certifies and says: (1) he/she is the applicant, or one of the owners or managers of the applicant corporation, named in the foregoing application, duly authorized to make this application on its behalf; (2) that he/she has read the foregoing application and knows the contents thereof and that each and all statements therein made are true; (3) that no person other than the applicant or applicants has any direct or indirect interest in the applicant’s or applicants’ business to be conducted under the license(s) for which this application is made; (4) all supplemental statements are true and accurate. 28. Signature of Applicant (original signature) License Number Expiration Date Printed name Title Date Received PLEASE DO NOT WRITE IN GRAY AREA ABOVE THIS LINE. – FOR STATE USE ONLY Fund 3018 Index 3018 Index 5624 CDPH 8679 (6/09) Date Payment Type Amount California Department of Public Health PCA 76212 Receipt Source 125700 Agency Source 49 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Home Medical Device Retailer License Application Instructions A separate application is required for each place of business. Please complete and/or amend this application as is most appropriate to your facility. Include the appropriate fee for each application as indicated in the fee schedule and payable to: CA DEPARTMENT OF PUBLIC HEALTH. This fee must accompany this application. Without the fee the application cannot be processed. Unsigned or incomplete applications cannot be processed. The following are further instructions on how to complete this application: Do not leave any sections blank. New Applicant / Renewal Applicant: Place an (X) in the box next to New Applicant if your firm has not previously applied for a Home Medical Device Retailer License at this location while under the current ownership. Place an (X) in the box next to Renewal Applicant if your firm has already obtained a Home Medical Device Retailer License for this location, and you are renewing that license. If your firm has changed location, ownership, or both, place an (X) in the box adjacent to the appropriate response. Check one box only. 1. 2. 3.–5. 6.–8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. Legal Name of Firm: Enter full name of business, corporation, company, or organization applying for licensure. DBA: Enter any other name(s) your company is doing business as. Facility Address: Enter the number, street, city, state, and zip code for this facility location. Mailing Address: Enter the full mailing address if different from the facility address. Facility Operator: Enter the full name of the person who manages the operations at this facility and their title. Facility Telephone Number: Enter daytime business telephone number of this facility. Facility FAX Number: Enter facility FAX number. 24-Hour Emergency Telephone Number: Enter telephone number to be called in the event of an emergency. E-mail Address: Enter facility e-mail address. Correspondent: Enter the name of the person to contact for information regarding this application and their title. Correspondent Telephone Number: Enter the daytime business telephone number of the contact person. Correspondent FAX Number: Enter the daytime business FAX number of the contact person. Country: Enter the country where your facility is located, if outside of United States. Website: Enter the website address for your business, if applicable Type of Ownership: Place an (X) in the box next to the appropriate legal description of the facility’s ownership. (Attach copy) Corporate Name: Enter corporate name if applicable. Enter state of incorporation if applicable. Owners’ or Officers’ Names: List the business owners’ or officers’ names and titles. Attach a list if needed. Type of Application: Place an (X) in the box next to the type of application you are submitting Type of Business Conducted: Place an (X) in the box adjacent to the type of business being conducted at this location and list business days and hours. Enter Business license , FEIN, and Seller’s Permit number and attach required copies. Type of Products Selling: Place an (X) in the box adjacent to the type of products your business will be selling. Check all that apply. Selling or Renting Legend Devices, Medical Oxygen, or Respiratory Equipment: Place an (X) in the boxes next to your answer for question a. and b. If you answered yes, provide the name of the exemptee and their license number. Medi-Cal or Medicare Provider: Place an (X) in the boxes adjacent to your answer to each question on provider types. Payment Codes: Your license fee is based on the type of activity at your facility. Based on the chart below, place an (X) in the correct payment code box on the first page (mark only one box A–C). License Category Fee Interval of Renewal and Fees Payment Code New Instate Firm 28. First license or Relocation A $850.00 Annually on renewal B Warehouse only ** $850.00 Renewal $425.00 First license and Annual renewal C LICENSE FEES ARE NON-REFUNDABLE AND NON-TRANSFERABLE TO OTHER LOCATIONS OR ENTITIES Provide original signature and print your name, print your title, and enter the date. MAKE CHECKS PAYABLE TO: CA DEPARTMENT OF PUBLIC HEALTH MAIL APPLICATION AND CHECK TO: Regular Mail: California Department of Public Health Food and Drug Branch - Cashier MS 7602 P.O. Box 997435 Sacramento, CA 95899-7435 Overnight Mail: California Department of Public Health Food and Drug Branch - Cashier 1500 Capitol Avenue, MS-7602 Sacramento, CA 95814 If you have any questions about this application, please contact the Home Medical Device License Voice Mailbox at (916) 650-6500 and leave a message with your firm name, your name, and your phone number and a staff member will return your call. You may also visit our internet web site at: http://www.cdph.ca.gov/programs/Pages/FDB.aspx for timely program news and a blank copy of this application form. The Food and Drug Branch must approve this application before a Home Medical Device Retailer license is issued. If changes are made during the application process, you may need to submit a new application with appropriate fees. Fees applied to this application are not transferable and are not refundable. Any material misrepresentation in response to any question is grounds for refusal or subsequent revocation of license, and a violation of the California Penal Code. All items of information in this application are mandatory. Failure to provide any of the requested information will result in the application being rejected as incomplete. CDPH 8679 (6/09) Fund 3018 Index 3018 Index 5624 PCA 76212 Receipt Source 125700 Agency Source 49 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com